Pregabalin Audit Template This template can be used to document the Pregabalin audit undertaken by practices as part of the Incentive Scheme. It has been produced to provide practices with a guide but may be adapted to suit the needs of the practice or individual audit. Practice Name Audit Undertaken By and Job Title Date of Audit Aim Background (Reason for audit being undertaken) To review a selected cohort of patients prescribed pregabalin in the practice and if appropriate, switch to a cost effective alternative or stop altogether. Pregabalin is an area of high cost prescribing and growth. Pregabalin prescribing costs Wirral CCG 1,460,625 million annually. Despite previous work in 2013 to reduce pregabalin prescribing, the CCG remains above the national average in terms of prescribing costs and items prescribed. Wirral guidelines for neuropathic pain now recommend pregabalin fourth line after amitriptyline, nortriptyline and gabapentin. They also recommend that conventional analgesics are tried first 1 Nortriptyline is more expensive than amitriptyline but better tolerated and is cheaper than gabapentin. Secondary care clinicians are keen that this second step is followed to avoid increasing the use of both gabapentin and pregabalin. Reducing prescribing by 10% in terms of cost could save 146K for the Wirral CCG. Audit Criteria/Audit Standard See Pregabalin Audit Sheet Audit Period (if different to audit The MM Team will review data in January Version 1.0 Page 1 of 6
date) Description of Method 2015 to determine if the target has been achieved. The MM team will also carry out a spot check on randomly selected patients within the cohort to ensure patients have been switched or stopped. Exclude patients who are prescribed pregabalin for diabetic neuropathy. Select a cohort of 20% of the remaining number of patients. Review this cohort of current patients prescribed pregabalin with a view to stopping medication altogether or changing patients to a cost effective alternative using current guidelines if deemed clinically appropriate. Results To be recorded using prescribing audit data sheet attached (pg 3) Action Plan (including timescales and need to re-audit) References 1. Wirral Clinical Guideline for the management of neuropathic pain http://mm.wirral.nhs.uk/document_uploads/guidelines/neuropathicpain-clinicalguidelinev2.pdf 2. An update on the drug treatment of neuropathic pain Part 1 DTB 2012; 50(10): 114-7 3. UKMi Q&A 408.1 How do you switch between pregabalin and gabapentin for neuropathic pain, and vice versa? 2012 4. Toth C Substitution of gabapentin therapy with pregabalin therapy in neuropathic pain due to peripheral neuropathy. Pain Medicine 2010; 11:456-465 Version 1.0 Page 2 of 6
Pregabalin Audit Sheet Patient ID Types of pain &/or neuropathic pain recorded with dates Other relevant diagnosed conditions with dates Is the patient under secondary care for pain? Please record speciality e.g. chronic pain team, orthopaedics. Is the patient under secondary care for other conditions? Yes/No Date of last contact Yes/No Date of last contact Pain history, including drugs prescribed, with dates Results of pain assessments and reviews with dates Current pain medication with doses and date started Compliance with pain medication Renal function (egfr) with date Possible action ie Switch/Stop/Optimise Dose Audited by: Date of audit: Version 1.0 Page 3 of 6
Summary of Findings Pregabalin Audit Practice name.date of Audit Summary of Actions Total number of patients prescribed pregabalin. Number of patients prescribed pregabalin (excluding diabetic peripheral neuropathy). These are the eligible patients for the audit. Number of patients in audited cohort (20% of above total) Number of patients stopped Number of patients switched to cost effective alternative Number of patients for whom dose was optimised Version 1.0 Page 4 of 6
Appendix 1 Dosing Information Gabapentin Dosing Information for an increasing dose Gabapentin can be given with or without food and should be swallowed whole with sufficient fluidintake (e.g. a glass of water). Standard schedule Day 1 Day 2 Day 3 Day 4 Day 5 Morning 300mg 300mg 300mg 300mg Midday 300mg 300mg 300mg Night 300mg 300mg 300mg 300mg 600mg Day 6 Day 7 Day 8 Day 9 Day 10 Morning 300mg 300mg 300mg 600mg 600mg Midday 300mg 600mg 600mg 600mg 600mg Night 600mg 600mg 600mg 600mg 600mg Accelerated schedule Day 1 Day 2 Day 3 Day 4 Day 5 Morning 300mg 300mg 300mg 300mg 300mg Midday 300mg 300mg 300mg 300mg 600mg Night 300mg 300mg 600mg 600mg 600mg Day 6 Day 7 Day 8 Day 9 Day 10 Morning 300mg 600mg 600mg 600mg 600mg Midday 600mg 600mg 600mg 600mg 600mg Night 600mg 600mg 600mg 900mg 900mg Based on individual patient response and tolerability, the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day. Slower titration of gabapentin dosage may be appropriate for individual patients. The minimum time to reach a dose of 1800 mg/day is one week, to reach 2400 mg/day is a total of 2 weeks, and to reach 3600 mg/day is a total of 3 weeks. 2 Elderly patients (over 65 years) and patients with compromised renal function may require dosage adjustment because of declining renal function. Somnolence, peripheral oedema and asthenia may be more frequent in elderly patients. Gabapentin dose adjustment based on renal function Creatinine Clearance (ml/min) or egfr Total Daily Dose (mg/day) 80 900-3600 50-79 600-1800 30-49 300-900 15-29 150 * -600 Version 1.0 Page 5 of 6 <15** 150 * -300 *To be administered as 300 mg every other day. ** For patients with creatinine clearance <15 ml/min, the daily dose should be reduced in proportion to creatinine clearance (e.g., patients with a creatinine clearance of 7.5 ml/min should receive one-half the daily dose that patients with a creatinine clearance of 15 ml/min receive). Gabapentin 100 mg capsules can be used to follow dosing recommendations for patients with renal insufficiency
Switching pregabalin to gabapentin in patients with normal renal function 3 This would be a straight switch, rather than titrating down the pregabalin dose and titrating up the gabapentin dose. Pregabalin total daily dose pre-switch Gabapentin total daily dose post switch (Toth study 4 ) Suggested daily dose of gabapentin 150mg 900mg 300mg tds 225mg 901mg to 1500mg 400mg tds 300mg 1501mg to 2100mg 2x300mg tds 450mg 2101mg to 2700mg 2x400mg tds 600mg 2701mg to 3600mg 3x300mg tds For daily doses of pregabalin below 150mg daily, e.g. 100mg, 75mg switch to gabapentin 100mg tds, and titrate up if necessary. Discontinuing gabapentin If gabapentin has to be discontinued it is recommended this should be done gradually over a minimum of 1 week (SPC). Stepping down and discontinuing pregabalin The SPC for Lyrica states that pregabalin should be discontinued gradually over at least one week, independent of the indication. NHS Gloucestershire recommends reducing the dose by 50-75mg per week http://www.gloshospitals.nhs.uk/sharepoint19/chronic%20and%20acute%20pain%20services%2 0Web%20Documents/Pregabalin%20review%20(neuropathic%20pain)%20mg%204%20(2).pdf Suggested withdrawal schedule for a dose of 150mg bd (based on table from above reference): Week 1 Week 2 Week 3 Week 4 Stop and Morning 150mg 75mg 50mg 25mg review Evening 75mg 75mg 50mg 25mg patient Version 1.0 Page 6 of 6